Retransplantation of the lung comes of age

Rehabilitative goals for patients undergoing lung retransplantation

Lung retransplantation (LRT) involves a second or subsequent lung transplant (LT) in a patient whose first transplanted graft has failed. LRT is the only treatment option for irreversible lung allograft failure caused by acute graft failure, chronic lung allograft dysfunction, or postoperative complications of bronchial anastomosis. Prehabilitation (rehabilitation before LT), while patients are on the waiting list, is recognized as an essential component of the therapeutic regimen and should be offered throughout the waiting period from the moment of listing until transplantation. LRT is particularly fraught with challenges, and prehabilitation to reduce frailty is one of the few opportunities to address modifiable risk factors (such as functional and motor impairments) in a patient population in which there is clearly room to improve outcomes. Although rehabilitative outcomes and quality of life in patients receiving or awaiting LT have gained increased interest, there is a paucity of data on rehabilitation in patients undergoing LRT. Frailty is one of the few modifiable risk factors of retransplantation that is potentially preventable. As such, it is imperative that professionals involved in the field of retransplantation conduct research specifically exploring rehabilitative techniques and outcomes of value for patients receiving LRT, because this area remains unexplored.

Lung retransplant. Experience of a referral centre

BACKGROUND

Lung retransplantation (LR) is a valid choice with a significant risk of perioperative morbidity and mortality in selected patients with graft dysfunction after lung transplantation. Our goal is to analyse our experience in LR in terms of survival and lung function.

METHODS

Retrospective study of patients undergoing LR (1990-2019).

VARIABLES

recipients and procedure, early mortality, survival and lung function in patients with CLAD. Quantitative variables (mean±SD); qualitative (%). Student's t test or χ2 was used. Survival was estimated using Kaplan-Meier, compared with Log Rank. A p < 0.05 was established as significant.

RESULTS

Of 784 transplanted patients, 25 patients (mean age 38.41-16.3 years, 12 men and 13 women) were LR; (CLAD (n = 19), pulmonary infarction (n = 2), airway complications (n = 2), graft dysfunction (n = 1), hyperacute rejection (n = 1), mean time to retransplantation: 5.41 ± 3.87 years in CLAD and 21.2 ± 21.4 days in non-CLAD. The 90-day mortality was 52% and 36.8% in the second period (p = 0.007), being higher in patients who required preoperative ECMO (80 vs. 20%, p = 0.04). The 1- and 5-year survival was 53.9% and 37.7%, respectively (p = 0.016). Survival of the CLAD group was greater (p = 0.08). Pre LR ECMO decreased survival (p = 0.032). After LR, FEV₁ improved an average of 0.98 ± 0.13L (25.6 ± 18.8%) (p = 0.001).

CONCLUSIONS

LR is a high mortality procedure that requires careful selection of patients with better results in patients with CLAD. The lung function of patients with CLAD improved significantly.

Safety and Efficacy of Steroid Pulse Therapy for Acute Loss of FEV1 in Lung Transplant Recipients After Exclusion of Acute Cellular Rejection

BACKGROUND

The standard treatment of acute cellular rejection after lung transplantation (LTx) is a high-dose steroid pulse therapy. In our center, this therapy is also the standard of care for LTx recipients with acute loss of forced expiratory volume in 1 second (FEV₁), after excluding specific causes such as acute rejection on biopsy. The aim of this retrospective study was to evaluate the safety and efficacy of steroid pulse therapy.

METHODS

From 2015 to 2018, 33 consecutive patients (17 male patients, mean age ± SD, 50.5 ± 12.5 years) were included. All patients underwent routine examinations to exclude acute cellular rejection and other specific causes. FEV₁ was routinely measured after 5 days, and 1, 3, and 6 months. Positive response to steroid pulse therapy was defined by increase of FEV₁ > 10%.

RESULTS

The mean decrease ± SD from baseline in FEV₁ at the start of steroid pulse therapy was 380 ± 630 mL (P = .02). FEV₁ changed after 5 days by 170 ± 180 mL (P = .0007), and after 1 month by 140 ± 230 mL (P = .70), 3 months by -60 ± 240 mL (P = .15), and 6 months by -80 ± 290 mL (P = .73). A positive response was observed in 21% of patients after 3 months and 12% after 6 months. High bronchoalveolar lavage (BAL) eosinophil count correlated with a higher FEV₁ after steroid pulse therapy. Serious complications were observed in 4 out of 33 patients (12%) with 1 fatal event (pneumonia).

CONCLUSIONS

Only a minority of patients after LTx with loss of FEV₁ after exclusion of acute cellular rejection benefit from steroid pulse therapy. Patients with BAL eosinophilia are more likely to respond. However, severe complications were observed.

Survival After Lung Retransplantation in the United States in the Current Era (2004 to 2013): Better or Worse?

BACKGROUND

To understand the current patient survival after lung retransplantation (LRTx) in the United States, which has historically been worse compared with primary lung transplantation (LPTx).

METHODS

The United Network for Organ Sharing (UNOS) registry was retrospectively analyzed to determine survival after adult LRTx performed in 604 (2.48%) of 14,850 patients from 2004 to 2013. After exclusions, 582 LRTx and 13,673 LPTx recipients were selected for analysis. Cox proportional hazards regression models were used to determine the prognosticators of survival after LRTx. Survival after LRTx and LPTx were compared using Kaplan-Meier analysis.

RESULTS

The median survival after LRTx was 2.6 years compared with 5.6 years after LPTx. One-year, 3-year, and 5-year survival rates were, respectively, 71.1%, 46.3%, and 34.5% for LRTx, and 84.3%, 66.5%, and 53.3% for LPTx (p < 0.001). On multivariate analysis, patients who had LRTx after a greater than 1-year interval survived longer (relative risk [RR] 0.53; 95% confidence interval [CI] 0.34% to 0.88%; p = 0.008). Lower survival was associated with single-lung transplantations (RR 1.49; 95% CI, 1.06% to 2.07%; p = 0.021), transplantations done between 2009 and 2013 (RR 1.40; CI, 1.01% to 1.94%; p = 0.041), multiple (>1) retransplantations (RR 2.55; 95% CI, 1.14% to 5.72%; p = 0.023), and recipients requiring pre-transplantation ventilator support. The only significant donor variable for poor survival was death due to cerebrovascular accidents (RR 1.98; 95% CI, 1.23% to 3.18%; p = 0.004).

CONCLUSIONS

Patient survival after LRTx in the United States has improved compared with historical data but remains lower than LPTx. Careful recipient selection and preoperative optimization based on the factors identified in our study may help utilize resources better and improve survival after LRTx. Bilateral LRTx should be preferentially performed as much as possible. Poor candidates for LRTx include those requiring retransplantations more than once or within 1 year. Prospective multi-institutional studies are necessary to help better understand the actual role of these factors in LRTx.

An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome

Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.

Time-dependent changes in the risk of death in pure bronchiolitis obliterans syndrome (BOS)

BACKGROUND

The timing of disease onset may affect the prognosis in chronic lung allograft dysfunction (CLAD). The relationship between the timing of disease onset and the prognosis of CLAD and its sub-types, bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), was examined.

METHODS

Clinical records and pulmonary function data of 597 patients who underwent bilateral lung transplantation from 1996 to 2010 and survived for >3 months were examined.

RESULTS

Among 155 patients with a final diagnosis of BOS, patient survival after disease onset was significantly different according to disease-onset timing (BOS onset/post-BOS median survival: overall/1,438 days; <1 year/511 days; 1-2 years/1,199 days; 2-3 years/1,403 days; >3 years/did not reach median survival; p < 0.0001). The prognosis of RAS was generally poorer than that of BOS (overall post-RAS median survival, 377 days). Treating non-CLAD, CLAD, BOS, and RAS as time-dependent covariates, recipient sex-adjusted and age-adjusted Cox regression analysis demonstrated an overall mortality risk of BOS (reference: no CLAD) of 6.7 (95% confidence interval, 4.6-9.9). However, when patients survived 3 years without CLAD, the mortality risk of subsequent BOS was only 1.9 (95% confidence interval, 0.8-4.4) compared with no CLAD. The number of RAS patients was too small to obtain sufficient power to estimate time-dependent mortality risk.

CONCLUSION

Late-onset BOS showed a better prognosis than early-onset BOS. Studies that do not distinguish BOS from RAS may overestimate the mortality risk of BOS. Multicenter studies will be required to further elucidate risk factors toward the development of better management strategies for CLAD.

Pulmonary hypertension before first and second lung transplantation

BACKGROUND

Pulmonary hypertension (PH) is frequently encountered in patients with advanced lung disease before the first and second lung transplantation. We sought to determine whether there is any relationship between pulmonary hemodynamics obtained before first and second lung transplantation. We also assessed whether PH has prognostic implications in lung transplant patients going for second transplantation.

METHODS

We included consecutive adult (16-yr-old or older) patients who underwent lung re-transplantation, between 1997 and 2009, and had right heart catheterization before their first and second lung transplantation.

RESULTS

Eighteen patients were included in the study. Age at first transplantation was 50.4 (SD 10.4) yr, and bronchiolitis obliterans syndrome (BOS) in the transplanted lung was the only indication for re-transplantation. PH was observed in 39% of the patients before the first lung transplant and in 56% of the subjects before re-transplantation (p = 0.91). Pre-capillary PH was present in 28% (n = 5) and 33% (n = 6) of the patients before first and second lung transplantation, respectively. None of the hemodynamic variables obtained before the first transplant predicted the development of PH before re-transplantation. PH before re-transplantation did not predict survival or development of BOS after re-transplantation.

CONCLUSIONS

PH before initial lung transplantation did not predict the development of PH before the second transplantation. In our cohort, PH before second lung transplantation did not predict outcomes after re-transplantation.

Lung retransplantation

Lung retransplantation comprises a small proportion of lung transplants performed throughout the world, but has become more frequent in recent years. The selection criteria for lung retransplantation are similar to those for initial lung transplant. Survival after lung retransplantation has improved over time, but still lags behind that of initial lung transplantation. These differences in outcome may be attributable to medical comorbidities. Lung retransplantation appears to be ethically justified; however, the optimal approach to lung allocation for retransplantation needs to be defined.

Survival of primary and repeat lung transplantation in the United States

BACKGROUND

This study was undertaken to compare survival between primary and repeat lung transplant recipients and to identify survival predictors after repeat lung transplantation.

METHODS

Data for 10,846 primary and 354 repeat lung transplant patients were extracted from the United Network for Organ Sharing registry. Propensity score matching was used to examine balance in the distribution of potential observed confounders and to match the sample in terms of the probability of repeat lung transplantation given pretransplant characteristics alone. Matching based on the propensity score was used to compare survival between the primary and repeat lung transplant groups. A Cox regression model was used to identify risk factors for death in the cohort of patients receiving lung transplant.

RESULTS

Considerable bias between the primary and repeat lung transplant groups was found in the sample. Patients with high propensity scores tended to carry high-risk profiles. Propensity score matching revealed incomplete overlap of covariate distributions between primary and repeat transplant groups. For those subjects who could be matched for the set of potential confounding variables, no difference in survival time was observed between primary and repeat lung transplant patients. Functional status and serum creatinine level were the two clinically important risk factors for predicting the survival of repeat transplant patients.

CONCLUSIONS

The current study revealed that direct comparison of the survival of primary and repeat lung transplant patients is biased by nonoverlap in the distribution of potential confounders. Using propensity score matching we adjusted for this bias and found that there was no significant difference in survival between first and second transplants.

Outcomes after Lung Retransplantation in the Modern Era

RATIONALE

Characteristics of and survival estimates for recipients of lung retransplantation in the modern era are unknown.

OBJECTIVES

To compare lung retransplant patients in the modern era with historical retransplant patients, to compare retransplant patients with initial transplant patients in the modern era, and to determine the predictors of the risk of death after lung retransplantation.

METHODS

We performed a retrospective cohort study of patients who underwent lung retransplantation between January 2001 and May 2006 in the United States (modern retransplant cohort). The characteristics and survival of this cohort were compared with those of patients who underwent first lung retransplantation between January 1990 and December 2000 (historical retransplant cohort) and patients who underwent initial lung transplantation between January 2001 and May 2006 (modern initial transplant cohort).

MEASUREMENTS AND MAIN RESULTS

Modern retransplant recipients (n = 205) had a lower risk of death compared with that of the historical retransplant cohort (n = 184) (hazard ratio, 0.7; 95% confidence interval, 0.5-0.9; P = 0.006). However, modern retransplant recipients had a higher risk of death than that of patients who underwent initial lung transplantation (n = 5,657) (hazard ratio, 1.3; 95% confidence interval, 1.2-1.5; P = 0.001), which appeared to be explained by a higher prevalence of certain comorbidities. Retransplantation at less than 30 days after the initial transplant procedure was associated with worse survival.

CONCLUSIONS

Outcomes after lung retransplantation have improved; however, retransplantation continues to pose an increased risk of death compared with the initial transplant procedure. Retransplantation early after the initial transplant poses a particularly high mortality risk.